Clinical Conversations

In the early waves of the Covid-19 pandemic why did patients in unionized nursing homes, have a roughly 10% lower rate of mortality than those in non-unionized ones? A report in Health Affairs tries to sort out the possible reasons.
Listen to our 13-minute interview, which raises the question: Should you send your patients to non-unionized facilities?
Health Affairs article
The post Podcast 291: Unionized nursing homes had lower mortality during Covid-19 first appeared on Clinical Conversations.

The U.S. Preventive Services Task Force recently issued its sixth set of guidelines on using daily aspirin to prevent cardiovascular disease. The guidelines appeared in JAMA — whose editors asked our guest, Dr. Allan Brett, to write an editorial evaluation.
This edition carries Brett’s advice on using the new guidelines in daily clinical practice.
Brett’s JAMA editorial
USPSTF recommendations in JAMA
[Running time: 15 minutes]
The post Podcast 290: USPSTF’s new take on aspirin and primary prevention of CVD first appeared on Clinical Conversations.

Saline or balanced crystalloids? The question of which resuscitation fluid to use in clinical practice seems to have been settled by recent research findings — or at least settled in favor of balanced crystalloids. But wait, our guests see slight differences that may affect your choice.
Patricia Kritek practices critical care medicine at the University of Washington. In this edition, she pilots a discussion with Todd Rice of Vanderbilt. He has studied the problem carefully, having published two studies in the New England Journal of Medicine in 2018; more recently, he’s written a meta-analysis of the problem in NEJM Evidence.
Listen in on a truly clinical conversation.
[Running time: 16 minutes]
The post Podcast 289: Saline versus balanced crystalloids — what to choose first appeared on Clinical Conversations.

Spend 15 minutes with Dr. Natalia Shevchuk, whom we interviewed by candlelight last month. She is sheltering in the Odessa region now, having left the Donetsk area.
This time, she relates how she lost a colleague in Russia’s attack on the Kramatorsk railway station and found another she’d feared lost in Mariupol. She told us that she’s impressed by her patients’ willingness to fight, despite their opioid dependence.
The narrative can be confusing at times, and following closely will require having a map of Ukraine handy. A technical glitch or two complicated things, but you’ll get the main idea: Ukraine needs help.
[Running time: 15 minutes]
The post Podcast 288: Following up with a Ukrainian narcologist first appeared on Clinical Conversations.

During the American Academy of Neurology’s 2022 meeting in Seattle, Dr. Richard Lipton of Albert Einstein College of Medicine took questions from Dr. Teshamae Monteith (U. Miami) and Joe Elia.
Lipton’s group sought to characterize the impact of patients’ monthly headache days on their quality of life, especially the role of depression, allodynia, and anxiety. (Read the conference’s abstract here.)
[Listening time: 14 minutes]
Please leave a comment below to suggest how we can improve these interviews.
The post Podcast 287: Thinking about quality-of-life in migraine first appeared on Clinical Conversations.

Dr. Natalia Shevchuk (pictured above) treats substance use disorders in Ukraine’s Donetsk region. Her face is candlelit because her town is under curfew, and people aren’t allowed to put on their room lights (if they have electricity) in the hours of darkness, lest Russian bombardments use the lights as guides.
She talked with Dr. Ali Raja and Joe Elia via Zoom about her work and her concerns for colleagues in Mariupol she’s not heard from for weeks. It’s wartime and nothing is running as usual.
But let her tell you all about that.
Here is a transcript.
[Running time: 20 minutes]
The post Podcast 286: Talking about addiction treatment by candlelight from Ukraine’s Donetsk region first appeared on Clinical Conversations.

Gastroesophageal reflux, or GERD, was the focus of a revised set of guidelines issued in January in the American Journal of Gastroenterology. Given the frequency of that condition in primary care clinics, internist and NEJM Journal Watch editor-in-chief Allan Brett proposed a discussion about the practical application of these guidelines with David Bjorkman. Dr. Bjorkman, a gastroenterologist, delivers much practical advice on the matter.
[Listening time: 24 minutes]
Journal Watch summary on the guidelines
American Journal of Gastroenterology containing the guidelines
Transcript of the discussion
The post Podcast 285: GERD’s revised guidelines — an internist and a gastroenterologist discuss them. first appeared on Clinical Conversations.

Some 85 years ago Guernica was bombed, and after that came Dresden, Coventry, Hiroshima, Bach Mai, and the rest. This episode of Clinical Conversations asks how it might be possible to help clinicians under bombardment in Ukraine. As you will hear, one hospital in Chernihiv keeps all but essential staff away from its buildings when they are not on duty — for fear of losing them to Russian attacks.
A neurologist in Chernihiv, Serhiy Kareta, and a Ukrainian American trauma surgeon based in Philadelphia, Roxolana Horbowyj, join the Mass. General’s Ali Raja and NEJM Group’s Joe Elia in a conversation about the clinical situation in Ukraine and what listeners can do to help.
Here is a link to the Ukraine Ministry of Health’s humanitarian needs list
Transcript of the interview
[Running time: 20 minutes]
The views and opinions expressed in these blogs are not necessarily those of NEJM Journal Watch or NEJM Group.
The post Podcast 284: The clinical situation in Ukraine first appeared on Clinical Conversations.

You want more evidence that post-recovery vaccination against Covid-19 reinfection helps? Here is a careful study from the U.K. that followed some 35,000 health care workers — initially without symptoms — in over 100 institutions there. Starting in June 2020 the SIREN study tested these people regularly, with blood sampling every month and nasal swabs every 2 weeks during the period when the Delta variant was the greatest threat. Almost a third of the group, although asymptomatic, showed seropositivity by the time the vaccine was introduced to the U.K. in December 2020.
Dr. Susan Hopkins, the senior author of the paper just published in the New England Journal of Medicine, explains SIREN’s results. The short version is that the vaccine was effective — up to 85% after the first dose — and its protection waned to about 50% some 6 months after a second dose. Among those who were seropositive before the arrival of the vaccine, vaccination showed a remarkable 90% effectiveness after the first dose, and that effectiveness remained high more than 18 months after their earlier infection.
New England Journal of Medicine study
[Running time: 11 minutes]
Transcript of the interview
The post Podcast 283: More data — this time from the U.K. — about post-Covid vaccination first appeared on Clinical Conversations.

Governments’ directives about how and when to vaccinate people who’ve recovered from Covid-19 vary widely. But, according to this episode’s guest, Dr. Ronen Arbel, they all say they don’t have enough evidence to set firm policy. So, Arbel and his colleagues set out to collect evidence from some 150,000 patients’ records in Israel who’d recovered from the earliest waves of the pandemic.
About half the patients subsequently received at least one shot of the Pfizer-BioNTech vaccine, and all were followed over a period of some 9 months. Arbel’s group, using the patients’ health records, tracked how many became reinfected with Covid-19 — during that interval, the Delta variant was predominant. They found that reinfection was roughly fourfold higher among the unvaccinated; they also observed less benefit among patients aged 65 and older; in addition, the results from one or two shots were statistically the same.
Listen in to what this means for practicing clinicians.
[Running time: 15 minutes]
New England Journal of Medicine
TRANSCRIPT OF THE INTERVIEW 
Joe Elia:
We have all heard people say that they have had COVID-19 and as a result are immune, but would vaccination boost that naturally acquired resistance?
You’re listening to Clinical Conversations from the NEJM Group. I’m Joe Elia, and I’m joined by my co-host Doctor Ali Raja who is in the department of emergency medicine at Mass. General Hospital and a professor of emergency medicine at Harvard Medical School.
We’re about to interview Doctor Ronen Arbel on Zoom from Israel. His paper on the effectiveness of the Pfizer BNT vaccine among the recovered has just been published in the New England Journal of Medicine. Doctor Arbel does health outcomes research at Clalit Health Services and lectures on health systems management at the Ben-Gurion University of the Negev. Welcome Doctor Arbel.
Dr. Ronen Arbel:
Thank you for having me. It’s a great honor.
Dr. Ali Raja:
Thank you, Doctor Arbel. First of all, could you please for our listeners describe briefly the problem that you and the team investigated?
Dr. Ronen Arbel:
Okay. So, if you look around the U.S. CDC, European CDC, or the UK, each one has a different policy regarding when and how should I vaccinate the recovered subjects or patients for COVID-19, and they all say we don’t have any evidence. If we start with the…I think the most extreme is the United States. CDC said “We don’t have any evidence, so let’s ignore. We are ignoring your infection-induced immunity and you’re going to get vaccinated.”
Like all the others, the EU and other countries than the U.S. have other policies. The UK has a different policy. Israel has a different policy, and they all said “We don’t have evidence.” The only evidence actually that we found when we looked at this was a 600-patient study from Kentucky, which is probably not enough for significant evidence for the world. So, we thought this was a very important clinical issue. We always look what is the clinical question.
I’m a physician. I have a patient who recovered. Should we vaccinate? What would be the benefits? Of course, are there any safety issues? And that was the question. We had no clue what is the answer.
Dr. Ali Raja:
That makes perfect sense. And you mentioned the smaller study from Kentucky. It looks like you did this by reviewing the medical records of some 150,000 people in Israel who’d recovered from COVID-19. Is that right?
Dr. Ronen Arbel:
Yeah. Actually, we looked at all the patients in our healthcare organization [Clalit met the eligibility criteria. So, that was the number. It was for nine months, not just for a couple of weeks — a couple of months was done in Kentucky.
Joe Elia:
And the Clalit organization — you used their medical records. They ensure — or care for — I should say, about half the population in Israel. Is that correct?
Dr. Ronen Arbel:
Yes. 54 percent. And about two thirds of the patients above 65.
Joe Elia:
So, briefly, what did you find? Your primary and secondary findings, what were they?
Dr. Ronen Arbel:
So, the primary finding, first of all, we saw an interaction with age, so that’s why we recorded by two age groups. Up to 65 years old, we saw about 80 percent reduction in reinfection rates and the other rate was about 60 percent reduction.
Joe Elia:
In the older group.
Dr. Ronen Arbel:
Yeah. In the older group. That’s our main findings. What is very interesting we think, it’s only secondary, but very interesting, with one shot is enough. We didn’t see any benefit, any additional protection from a second shot. It was our hypothesis by the way. It’s very interesting that you said “boost natural immunity.” That’s the way we look at it. I mean, you can see there are a lot of studies that show the infection-induced immunity is at least as good as vaccine-induced immunity.
Of course, if you survive COVID and all the problems (long COVID), then the question, if it’s similar to a primary vaccination then it’s really reasonable that one shot will act with some kind of booster, which was your first word, right? How do you boost natural infection-induced immunity?
So, this is the biology that we saw. It was a nice study and it’s very similar to our results on the second one. I think it’s important because I think Eric Topol said, “You know, why does the CDC ignore [natural immunity]?” It’s like you’re already reading over our paper.
You want your patients to get vaccinated, it has to make sense. You cannot say “Ignore it; we don’t care that you are recovered.” I mean, the science says it does matter, but still, importance of study, you have a protection from your infection-induced immunity, but you can boost it and you should boost it by a vaccination, but a single one is enough.
Joe Elia:
And this work was done mostly, maybe even exclusively, among those who recovered from the Delta variant. Is that right?
Dr. Ronen Arbel:
No. Exposure was to the Delta variant. Some of them recovered from the original, the wild type and some from alpha. Okay. After Delta, by the way, there were very little reinfections. What we see now, we saw in Delta many more reinfections and you see in Omicron really much, much more reinfections. But after Delta, the numbers were really, really small. So, I think it was a very important to see what happens with the Delta.
Dr Ali Raja:
So, given the fact this was an exposure of the Delta variant, any thoughts about what this might mean with Omicron?
Dr. Ronen Arbel:
I was sure that you’d ask. Of course, it’s a great question. We don’t have a study on that yet. It’s probably too soon, but if we look at what…if we can learn from the past (which I’m not sure in COVID, right?) you see that in beta you didn’t see any reinfections. In Delta, you saw many more reinfections. In Omicron, you see many, many more reinfections.
Hopefully, we did not check this, we need to research this. We can hypothesize, I’m not sure what the results will be, but we’ll have I don’t know if a similar effect, but an effect of the vaccine on your reinfection risk. But the basic reinfection risk, that’s very clear.
The basic reinfection risk is going higher and higher. It was higher in Delta, and it was much higher in Omicron. So, if we assume…we’re not sure. If we assume that we have a similar effect and since the basic reinfection rates are much higher, the absolute effect should be higher assuming the same hazard ratio, but again, we did not research this yet. So, it’s just an assumption.
But we need to act all the time, and Israel is doing it, you can see like the fourth vaccination and the uncertainty. I mean, we don’t have evidence. We can just look at what we understand until now. That’s why Israel decided on a second booster, right? — a fourth vaccination — because the first booster was a huge success. Is the second booster a huge success?
We actually have some results on this, and our results are not published, but the minister in Israel published. It’s too soon to really tell but the decision was made. You don’t have time. Do we have the luxury to wait to see if vaccination helps in Omicron? No. It’s spreading like crazy.
Dr. Ali Raja:
That’s a great point. So, much of what public policy has been based on has had to be the data that we have available now even though we’re doing studies, and there will be more data in just a few weeks or months. You mentioned, Doctor Arbel, that the lack of a difference between one shot and two wasn’t a huge surprise for you because it makes sense given the modeling, were there any results that you did find surprising?
Dr. Ronen Arbel:
We actually did not know what would be the effect. I think 80 percent was probably higher than what we thought. We did not expect that in the older age group [vaccination would] have less of an effect. This age group interaction was discovered in the analysis, and we didn’t know. We don’t know when we go into the study what the results will be. I must point out here, it’s very important to say this is not in any way funded by Pfizer or any other company. All of our researchers are totally unbiased really and I think it’s very important.
So, we report what we find and don’t look at what will Pfizer…you know, they may like the first part. They probably don’t like the second part because you don’t need a second vaccination or a third vaccination. So, we are very strict not to get industry funding for these studies to make sure to really…I think it’s important to ensure that there is not even…of course, we are unbiased, but to make sure there is not even a suspicion of bias. Okay.
So, we can freely report what we see and be focused and that’s the advantage of our team that has all the clinical physicians who are leading this effort in Israel. They always push for the clinical question: “Should I vaccinate? How many vaccinations should I do?” These are really important clinical questions. That’s what we’re trying to answer.
Dr. Ali Raja:
So, let me actually ask you Doctor Arbel, I’m an emergency physician. I see patients every day, many of whom have had COVID, and they’re recovered. Some of those…fewer here in Massachusetts, but many still here and around the country look at me and say I just had COVID, I don’t need to get vaccinated. What does this mean in terms of the conversations I have with them, or a primary care doctor, or a pediatrician, what does this mean for the physicians who are actually seeing patients who have had COVID? What can we use this data to say?
Dr. Ronen Arbel:
So, the easy answer is, “You recovered from COVID, you have some coverage, but you can improve it significantly, dramatically, by one more vaccine.” I think it’s very simple.
Joe Elia:
Okay. Well, we want to thank you Doctor Arbel for your time with us today.
Dr. Ronen Arbel:
Thank you. It’s a great honor.
Joe Elia:
The pleasure is ours, but what’s the next step? Are you going to be investigating Omicron and its effects?
Dr. Ronen Arbel:
So, right now, we are looking in I think some of the major clinical questions, a second booster. The real-world effect on this of oral medication. Especially Pfizer. Especially in the vaccinated because all these studies have been done in unvaccinated patients. Most of these patients are vaccinated. This is a big question. We don’t know from the RCTs [randomized trials], is it working on vaccinated patients? We should have the results soon.
Dr. Ali Raja:
Those are exciting. That is such an important question.
Joe Elia:
That was our 282nd Clinical Conversation. We come to you from the NEJM Group and the writers and editors of NEJM Journal Watch. Kristin Kelley is our executive producer. I’m Joe Elia.
Dr. Ali Raja:
And I’m Ali Raja. Thanks for listening.
The post Podcast 282: Vaccination after Covid-19 recovery prolongs natural immunity to reinfection first appeared on Clinical Conversations.